Rebalancing Long-Term Care Systems in Washington: Experience up to July 31, Abbreviated Report

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1 : Experience up to July 31, 2005 Abbreviated Report submitted to the Centers for Medicare & Medicaid Services (CMS), Advocacy and Special Initiatives Division CMS Project Officer, 9/1/2004 to 4/15/2006, Mary Beth Ribar CMS Project Officer, 4/15/2006 to present, Dina Elani Researchers on the Project University of Minnesota School of Public Health Rosalie A. Kane, PhD, P.I, Robert L. Kane, MD, Co-PI Reinhard Priester, JD, Project Coordinator Donna Spencer, Data Manager Center for Community Integration K Charlie Lakin, EdD, Investigator School of Social Work Terry Lum, PhD, Data Analyst CNAC Corporation Linda Clark-Helms, CNAC Project Director National Academy for State Health Policy, Portland, ME Robert Mollica, Investigator PAS Research Center, University of California, San Francisco Charlene Harrington, PhD, RN, Investigator Martin Kitchener, PhD, Investigator Consultants Charles Reed, Olympia, Washington Dann Milne, Denver, Colorado The overall project is being conducted through a Task Order under a CMS Master Contract between CMS and the CNA Corporation, Arlington, VA, and subcontracts and consultant agreements between CNAC and the various researchers. The 3-year study calls for case studies of the experience of 8 states other states in the study are: Arkansas, Florida, Minnesota, New Mexico, Pennsylvania, Texas, and Vermont. The baseline case study covers a period through July 31, Updates will be prepared for the period ending July 31, 2006 and A slightly earlier version of this Abbreviated Report was presented for discussion at a CMS Open Door Forum, February 22, The statements and opinions in the report are those of the writers and do not necessarily reflect the views of CMS or any of its staff, or the State liaisons to the project, or any other state staff or persons who spoke to us from participating states We thank the Washington liaison to the study, Kathy Leitch, Assistant Secretary, Director of the Aging and Disability Services Administration (ADSA) in the Department of Social and Health Services, and Penny Black, who at the time this report was prepared was the Director of ADSA s Home and Community Based Services Division.

2 Table of Contents Highlights... 1 Context... 2 Real Choice Systems Change (RCSC) Grants... 3 Programs and Services... 3 Featured Management Approaches... 4 CARE System for Assessment and Case Management... 4 Access Management... 4 Fast Track Eligibility... 5 Nursing Home Transition... 5 Independent Providers and Home Care Quality Authority... 6 Quality Assurance and Improvement... 6 Caseload Forecasting... 7 Quantitative Markers of Rebalancing... 7 Changing Patterns in Nursing Home Use as Marker of Rebalancing... 7 Balance Between Institutional and Community Care... 8 Conclusion Issues for Future Observation Rebalancing in the State of Washington Abbreviated Report, p. 1

3 : Abbreviated Report Highlights The State of Washington has made outstanding progress towards a system of long-term care that maximizes choice and promotes community integration. 1 It has exhibited a steady commitment towards expanding HCBS services, dating back to the establishment of the statefunded CHORE services program in Among the highlights: A consolidated management structure where policy, implementation, and budget control are combined in a single governmental entity, the Aging and Disability Services Administration (ADSA). Initially, the ADSA focused on older people and people with physical disabilities, but recently services for consumers with mental retardation and developmental disability were integrated within ADSA. Funding for LTC is designated and managed in a single appropriation, giving ADSA the flexibility to adjust budgets according to programmatic needs (for example, expanding waiver services without seeking a supplemental appropriation). Credibility with executive branch and legislative officials by establishing a track record for reducing the nursing home census and producing regular reports that track caseloads and spending. Strong and consistent leadership at state and regional levels over decades of program development, and by a well-articulated vision for long-term care that is embedded in legislation and is widely understood and promulgated. A unique assessment and information system, which combines data about consumers and information on the service they receive. It is built on a modularized assessment that is entered electronically by case managers, and permits ready supervision and training of personnel, quality assurance, forecasting, and planning. This system, known as CARE (Comprehensive Assessment and Reporting Evaluation) has built-in algorithms for equitable care planning within and across consumer populations. CARE assessments are used to access not only waiver services but also Medicaid state plan personal care services and state funded services. 1 This abbreviated report is a synopsis of a much longer report on rebalancing long-term care systems in Washington, performed under contract between the University of Minnesota and CNAC Corporation through a Master Contract between CMS and CNAC. The full-length report, which contains organizational charts, timelines, references, and much more detail, appears on the website HCBS.org and on the University of Minnesota Principal Investigator s Website Similar abbreviated and full case studies have been prepared for the States of Arkansas, Florida, Minnesota, New Mexico, Pennsylvania, Texas, and Vermont. The case study covers a period up to July 31, 2005; subsequent reports will update the information as of July 2006 and July Rebalancing in the State of Washington Abbreviated Report, p. 1

4 A well-developed capacity for personal care delivered by independent providers (IP). As a result of a ballot initiative in 2001, the state created a Home Care Authority, which is appointed by the Governor, is largely comprised of people with disabilities, and is a resource for both providers and consumers in the IP system. IP providers are vigorously represented by the Service Employees International Union (SEIU), and the workers, including those who are family members of the consumer, enjoy competitive wages and benefits. An array of residentially based services that are integrated into the HCBS programs, and has established innovative quality monitoring approaches for all residentially based services, ranging from nursing homes to small family homes. A fast-track system to facilitate access to HCBS services for all applicants, including potential consumers in hospitals. At this point, the state s primary challenge is to maintain its relatively advanced stage of development and to make improvements in targeted areas, such as assisting people with DD to receive care in more integrated settings, managing the growth of the Independent Provider (IP) model of home care, investing in Information Technology, and better meeting the needs of consumers with mental illness. Context The state legislature is well informed about long-term care. Numerous nurses and other health professionals have been elected to the legislature and serve on the Health Committee. The state has a tradition of bringing public policy issues directly to the voters through ballot initiatives. This has a mixed impact on LTC reform. For example, passage of Initiative 601 in 1993, limiting state spending to a three year rolling average of inflation and population growth, has hampered innovation. On the other hand, in 2001, the successful Initiative 775 approved formation of a Home Care Quality Authority and a union contract and wage levels for Independent Providers of home care services. In a rapid time period, the union representing Independent Providers has become an influential political force, rivaling the nursing home lobby in its power. Parents of consumers living in state institutions for mental retardation and developmental disabilities, combined with unions of state employees working in this sector, have slowed progress in transitions to the community for this population. Rebalancing in the State of Washington Abbreviated Report, p. 2

5 Real Choice Systems Change (RCSC) Grants Washington received three RSCS change grants between 2001 and 2004, totaling 2,763, The design of the projects all fit within Washington s larger scheme for enhancing consumerdirection, and bringing all populations needing service into a unified service system. Collectively, the grants explored cash and voucher options, adapted the assessment and careplanning tools used for seniors and people with physical disabilities so that they would be more appropriate for people with developmental disabilities, permitted work on a Quality Assurance/Quality Improvement Outcome Tool, and assisted in transitions both from nursing homes and State psychiatric hospitals. Collaboration with the State housing authorities was built into two of the projects. The Aging and Disability Resource Center, in the planning stages during our baseline case study and funded in October 2005, will be piloted in the Tacoma area, apply to all disability groups, involve independent living centers, expand the Comprehensive Assessment and Reporting Evaluation System to include state funded services, Benefit Checkups, and AOA funded services, and entail vigorous social service marketing to expand awareness of services in the State of Washington. Washington s own data systems will be utilized to examine the effectiveness of these measures. Programs and Services The bulk of services are authorized under 2 large HCBS waivers: the (COPES) waiver, established in 1983 for seniors and adults with physical disabilities; and the Community Alternatives Waiver, established in the same year for the MR/DD population, but eliminated in 2004 and replaced by 4 MR/DD waivers. The COPES waiver is managed by the Home and Community Services Division and DD waivers by the Developmental Disabilities Division. Noteworthy Medicaid state plan and state-funded community LTC services include: The Medicaid State Plan Personal Care program, available for consumers who have an unmet or partially met need with at least three activities of daily living. A single entry point is used for state plan services and COPES services, which are managed in tandem. About 40% of personal care consumers under the state plan are under age 65. The CHORE program is a small personal care program funded by state general revenues and serving consumers not eligible for Medicaid personal care or the COPES waiver program. Enrollment in the CHORE program has declined recently and appropriations remain at FY 2001 levels. 2 Awards included a Nursing Facility Transition Grant (Supported Transitions) in 2001, used to assist people under age 65 to leave nursing homes; a Real Choice System Change Grant ( Community Living Initiative ) in 2002, which was used to design and implement a variety of systemic approaches across state agencies for Community Living Initiative, including enhancing training for community-direction, developing payment mechanisms, and developing a quality outcome tool; and Money Follows the Person Grant in 2003, which was used to develop assessment tools and interactive service plans for adults and children with developmental disability. In 2005, after the period covered in this baseline case study, Washington received an Aging and Disability Resource Center. Rebalancing in the State of Washington Abbreviated Report, p. 3

6 The New Freedom Waiver, a 3-year pilot program (through September 2007) in King County (Seattle) and Clark County (Vancouver) is funded through a Cash and Counseling infrastructure grant from the Robert Wood Johnson Foundation (with CMS match). Services began in 2005 and targets were for 100 enrollees by September 2005, 400 by September 2006 and 750 by September The program will offer consumers the opportunity to manage the full array of services purchased within their care plan and to purchase equipment and other goods related to their service needs. Featured Management Approaches CARE System for Assessment and Case Management The Comprehensive Assessment and Reporting Evaluation (CARE) System, an exemplar of an investment in Information Technology to guide a long-term care system, illustrates how a good assessment and information system and investment in training field personnel in its use can inform every element of a state s LTC system. Motivated originally by a legislative directive to develop a new classification and payment methodology that bases payment for services to the consumer s needs, CARE has transformed the delivery and management of LTC services throughout the state and has resulted in a paperless, modular state-of-the-art assessment process. The CARE assessment tool includes all elements in the nursing home Minimum Data Set (MDS), along with other direct consumer assessments with the goal of permitting comparisons of client characteristics across programs and settings, including nursing homes. After the assessment tool was tested for reliability and linked to a payment algorithm, CARE was implemented in 2003 with intensive training for assessors and case managers to accustom them to the use of laptops and pull-down menus. This approach forces case managers to take all relevant information into account during the assessment and prevents assessors to proceed if fields that should be complete are blank. A time study was performed that connected hours of service use and client characteristics and Resource Allocation algorithms that allow for an automated assignment of a base number of hours. Separate Resource Allocation algorithms are used for residential settings, such as adult family homes, enhanced adult residential care, and assisted living. The CARE tool is currently also used with individuals with DD who are receiving Medicaid state plan personal care services and is being modified for consumers with DD who receive waiver services. When that process is complete, all care planning and allocation of resources will be incorporated into CARE. Access Management Access to services is managed through a large network of state regional field offices where financial and functional assessments are consolidated. The CARE tool determines functional eligibility and the decision-making built into the tool prepares a care plan and assigns the individual to one of 14 tiers based on the number, type and scope of unmet needs. Although case managers may over-ride those allocations, the intent of the computer algorithm is to promote equity in resource allocations and remove unconscious human bias. If eligible, applicants choose the setting and services that are appropriate based on the findings from the assessment. The case manager prepares the authorization and arranges services. Consumers who receive care in a residential setting or a nursing home continue to receive case management from an ADSA social Rebalancing in the State of Washington Abbreviated Report, p. 4

7 worker or registered nurse. Ongoing case management for in-home consumers, apart from the MR/DD waiver system, is the responsibility of the Area Agencies on Aging (AAAs). The ADSA allocated $36 million in 2005 to AAAs for ongoing case management for in-home COPES and Medicaid Personal Care State plan clients. AAAs receive $1,100 a year per consumer for case management services. ADSA reviews payment system data to enumerate the consumers who received an authorized service and determine the monthly payment for case management. Presently, ADSA is working to modify algorithms and incorporate MR/DD waivers into the CARE system. Fast Track Eligibility The Aging and Disability Services Administration (ADSA) developed procedures to expedite financial eligibility determinations. Care managers are permitted to presume Medicaid eligibility for in-home and residential services for adults with disabilities and elders who are being discharged from hospitals. If financially eligible, the case manager completes an assessment and service plan and authorizes services for 90 days. Moreover, because Federal Financial Participation is not available for services delivered to applicants who are not eligible for Medicaid, state funds are used to pay for services in the few instances in which the applicant is found ineligible. State officials believe that the financial risk due to errors is limited compared to the savings realized by serving a person in the community. The state believes that it has achieved substantial savings because of these policies. Applications from individuals living in the community (as opposed to those in hospital) may also be expedited. Applications are taken over the phone, by mail or during a home visit by the eligibility worker. The expedited process has reduced the average time required to make decisions from 37 days to 17 days. ADSA does not receive federal reimbursement for services that are delivered to beneficiaries who are falsely presumed to be eligible, but the error rate in this fast track system has been less than 1%. Nursing Home Transition In 1995, the ADSA re-assigned case managers from hospitals to each nursing home in the state to work with residents who are interested in relocating; recognizing that most people discharged from a hospital needed a short-term rehabilitation stay before they could return home. Each transition case manager is responsible for working with about 100 residents in 2-3 facilities during the relocation process. Case managers contact all nursing home residents who have been admitted from a hospital within seven days of admission to the nursing facility to inform them of their right to decide where they will live and discuss their preferences, likely care needs, and service options. Individuals admitted from a community setting who are Medicaid beneficiaries, or are likely to become a Medicaid beneficiary within 180 days, receive a preadmission assessment and options counseling. A full comprehensive assessment is completed when the resident expresses an interest in moving to the community. The case manager then develops a transition plan with the consumer. Lack of funds for housing and transition services is a recurring barrier for nursing home residents to maintain an existing independent living arrangement during a temporary nursing facility stay, to relocate from a nursing home to a less restrictive residential setting, or to establish an independent residence. In response, Washington now covers such services under the Rebalancing in the State of Washington Abbreviated Report, p. 5

8 waivers, tapping several sources of funds, including the Medical Institution Income Exemption Fund (MIIE), Community Transition Services (CTS), the Residential Care Discharge Allowance, the Civil Penalty Fund, the Assistive Technology Fund, and a Real Choice Systems Change Transitions Services grant. Independent Providers and Home Care Quality Authority By 2004, over half of all consumers of in-home LTC received services from independent providers. Individual providers in Washington are represented by the Service Employees International Union (SEIU) as a result of the passage of a referendum that also established the Home Care Quality Authority and bargaining rights for individual providers. The Home Care Quality Authority (HCQA) was created by Initiative 775 in 2001 and state legislation in 2002 to improve the quality of long-term in-home care services by recruiting, training, and developing a worker registry and by stabilizing the work force of individual providers through collective bargaining. HCQA has a nine member board and an executive director. In its first two years, HCQA helped improve the wages and benefits of the independent providers and developed a Registry to help match potential workers with consumers. HCQA contracts with local organizations to operate and maintain Referral and Workforce Resource Centers to help consumers find individual providers. The Centers maintain a database of individual providers who have passed a background check. Consumers can search for workers based on their needs, preferences, geographic location, language, and worker qualifications. The HCQA also developed an application form and interview guidelines to help consumers find prospective workers. For IPs, the HCQA developed training manual and a safety manual as well as information about peer mentoring, professional development, responsibilities to the consumer employer, and providing personal assistance. Independent providers must have a signed contract with ADSA and meet with the case manager to review the service plan before they can be reimbursed for providing services. Quality Assurance and Improvement ADSA utilizes innovative quality assurance and quality improvement approaches in nursing home, residential and in-home settings. The parameters of its quality assurance program are described in statute, which mandates the system be client-centered and promote privacy, independence, dignity, choice, and a home or home-like environment for consumers and establishes the goal of continuous quality improvement. The CARE system is integral to the quality assurance program. CARE data are used to generate a wide range of reports on the quality of in-home LTC services that allow supervisory and management staff to review and compare care plans, validate authorizations against care plans, monitor assessment and reassessment dates, maintain an accurate list of the number of consumers in each setting and ensure that case managers are making referrals for nursing services and responding to high risk consumers. Managers can compare the clinical and other characteristics of consumers across in-home and residential settings. Data can be sorted by case manager, supervisory unit, field offices, region, and statewide. The data allows ADSA managers to examine consistency in and completeness of the assessment and ensure compliance with the Rebalancing in the State of Washington Abbreviated Report, p. 6

9 assurances contained in the waiver. Managers reported that they use the data to identify and quantify costs savings, cost avoidance and issues that may indicate a need for further training. ADSA is also responsible for oversight and quality in residential settings. Responsibility for licensing and oversight of boarding homes was transferred from the Department of Health to ADSA in The Residential Care Services Division (RCS) was established to promote and protect the rights, security and well-being of individuals living in licensed or certified residential care facilities (boarding homes, adult family homes, nursing facilities, supported living services programs and ICF-MRs). RCS uses separate regional staff for nursing home and boarding home/alf inspections to allow more specialization. However, field managers cover all three settings to improve an understanding of regulatory framework. RCS has authority to impose a range of intermediate sanctions. However, the ban on admissions has been the most effective. RCS issues a press release to publicize the survey findings and remedies. Similar remedies are used for AFHs. Placing conditions on the license is the most often used remedy for AFHs. RCS provides consultation to nursing homes to improve compliance and quality. Quality Assurance Nurses visit nursing homes quarterly to review quality indicators e.g., the frequency of pressure sores. The nurse meets with the provider if they identify a problem area, discuss the problem area and suggest steps to address the problem, including a referral to the facility s quality assurance committee. A similar process was available to boarding homes but had to be dropped in 2003 because of a lack of funding. Caseload Forecasting Budgets for long term care services in Washington are based on caseload forecasts prepared by an independent Caseload Forecasting Council. The Council projects and adjusts the expected caseloads for nursing home and home and community based service programs for elders and adults with physical disabilities. The council consists of two individuals appointed by the governor and four individuals who are appointed by the House and Senate leadership. A member of the legislature chairs the Council. The forecast is submitted to the legislature and becomes the basis for determining the Governor s budget for nursing home spending, home and community services programs and case managers and is used by the legislature to develop the budget. Projections are based on historical trends and changes in policy that affect eligibility or the amount of services that may be authorized. Caseloads are projected for each month of the biennium. Quantitative Markers of Rebalancing Changing Patterns in Nursing Home Use as Marker of Rebalancing To assess the potential effect of HCBS on nursing home use, we examined the MDS data on all Washington nursing homes for the years 2002, 2003, and We reasoned that if HCBS was having an effect, the case mix in nursing homes should become higher, i.e., the level of disability (both functional and cognitive) should increase. Because nursing homes serve at least two streams of clients, one requiring post-acute care (PAC) after discharge from hospitals and Rebalancing in the State of Washington Abbreviated Report, p. 7

10 the more traditional long-term resident, we examined the case mix at two points in time: admission and three months after admission. The former would include the PAC population, but the latter should be a more direct reflection of long-term care that HCBS was intended to defray. Table 1 shows the changes in the NH case mix on admission and 3 months after admission for 2002, 2003, and The latter is a better test of the long-term care population. Between 2002 and 2004, the functioning level of elders admitted to NHs in WA deteriorated slightly from the average ADL score of in 2002 to an average ADL score of in 2004 (the possible score of the ADL variable is between 0 and 24: a higher score means higher ADL dependence). During the same period of time, the cognitive functioning of elders admitted into NHs improved slightly. The average CPS score went down from 1.87 in 2002 to 1.76 in 2004 (the possible score for CPS is between 0 and 6: a higher CPS score means lower cognitive functioning). Moreover, the rate of persons with no cognitive impairment or mild impairment increased. Table 1: Change in Nursing Home Acuity at Admission and 3 Months Post Admission in Washington, At Admission Mean ADL Mean CPS Months Post Admission Mean ADL Mean CPS The ADL functioning at 3 months after admission deteriorated slightly between 2002 and The average ADL scores in 2002, 2003, and 2004 were 13.99, 14.05, and respectively. However, the proportion of persons with no ADL dependencies did not change appreciably, although the rate for few dependencies did go down. For cognitive functioning, the CPS scores improved slightly between 2002 and The CPS score in 2002 is 2.63, dropped slightly to 2.58 in 2003 and further dropped to 2.52 in Moreover the proportion with no cognitive impairment increased. Balance Between Institutional and Community Care Figure 1 shows the average monthly enrollment of clients for each of 5 years, 2000 to (This presentation is different from that used for most of the state reports in this series. The numbers of clients tracked here are reported as client-years, i.e., they are converted to full year equivalents. Because it counts fewer beneficiaries, it raises the average cost per beneficiary. Care should thus be taken in comparing this measure across states.) The Senior and Disabled Waivers, which include the COPES waiver, the Medically needy Residential Waiver (begun in 2003) and the Medically Needy In-Home Waiver (begun in 2004), serve the largest numbers of persons, more than twice as many people as are in nursing facilities, a number which is declining. The number of persons served under the personal care program of the State Medicaid Plan is also growing rapidly; this program includes both aging and disabled participants and consumers with MR/DD. The MR/DD institutions are comprised of both the state habilitation centers (which house about 1000 people) and a small number of people in ICF/MRs. Rebalancing in the State of Washington Abbreviated Report, p. 8

11 Number of Clients Served State Res. Habilitation Centers + ICF-MRs Nursing Facilities Personal Care Supported Living MR/DD waivers Senior & Disabled waivers Figure 1. Clients Served in Selected Washington Programs, Rebalancing in the State of Washington Abbreviated Report, p. 9

12 Figure 2 shows the annual Medicaid expenditures for these same programs. MR-DD waivers, supportive living, and personal care under the State Medicaid Plan show the greatest growth. Senior and Disabled waivers (the COPES Waiver and the 2 Medically Needy Waivers) show growth in 2004, but the nursing home expenditures also grew. State Residential Rehabilitation Centers and MR/ICFs combined were stable Annual Expenditures, $ Millions State Res. Habilitation Centers + ICF-MRs Nursing Facilities Personal Care Supported Living MR/DD waivers Senior & Disabled waivers Figure 2. Expenditures for Selected Washington Programs, Figure 3 shows the Medicaid expenditures per client served by major programs over the five year period from 2000 to The small numbers of persons served in the remaining MR/DD institutions (largely the state rehabilitation centers) generated high and growing costs per client. Supportive living also showed substantial growth. MR-DD waiver costs per client costs grew until 2003 and then fell slightly. Costs per consumer in the MR/DD waivers still remained way above costs per consumer in the Senior and Disabled waivers. Rebalancing in the State of Washington Abbreviated Report, p. 10

13 Cost per Client Served State Res. Habilitation Centers + ICF-MRs Nursing Facilities Personal Care Supported Living MR/DD waivers Senior & Disabled waivers Figure 3. Per Capita Expenditures for Selected Washington Programs, The three figures together show Washington s substantial progress in rebalancing community care and point to further targets in reducing institutional services or making community care more efficient. Conclusion Recent developments have put the state of Washington at the forefront of long-term care system reform. A unionized independent provider sector has developed and expanded rapidly, fueled by state support to both the independent providers and consumers through the State s Home Care Quality Authority. As a consequence, independent providers are well paid and receive good benefits relative to such providers in other states. The CARE assessment tool allows case managers, supervisors and central office managers to oversee their programs proactively, providing unusual opportunities to identify and plan for a full range of consumer needs, including health care needs and mental health needs. State officials are in a position to identify and reach out to hard-to-serve groups, such as persons with mental health and chemical dependency problems. The innovative home and community service quality assurance systems allows managers to target practices that do not comply with the eligibility, care planning, payment, and case management standards. Rebalancing in the State of Washington Abbreviated Report, p. 11

14 Washington has particularly endeavored to make the financial and functional eligibility user friendly and quick, and it has organized its system so all services are accessed through a single computerized assessment system. Access to community care is enhanced through a vigorous effort to divert consumers from nursing homes by assigning case managers to work with consumers in hospitals and in post-hospital nursing home placements. Washington has an extraordinary capability to generate information about its own system, able to track providers or programs and link information about consumers, quality and costs. Issues for Future Observation Further efforts to downsize or eliminate the remaining state institutions for individuals with developmental disabilities. The further development of the CARE system to apply better to individuals with developmental disabilities. The growth and rising costs per capita for the Independent Provider sector, which is expected to soon equal or exceed that of home care agency services or community residential care settings. The evolution of the Home Care Quality Authority, a unique entity that is attempting to develop Referral Centers statewide. Its progress should be of national interest. The continued development and expansion of consumer direction within a strong case managed system. The development of innovative initiatives to increasing affordable housing and developing a data-driven collaboration between housing authorities and ADSA. Current exploration of reverse mortgages and specialized community residential care settings for specific target populations are of interest. The evolution of the Washington Medicaid Integration Partnership in providing an effective program for the most difficult to serve individuals who have a combination of mental health problems, chemical dependency problems, physical health problems, and need for long-term care. Rebalancing in the State of Washington Abbreviated Report, p. 12